The Evidence on Planned Home Birth


Home birth is a hot topic among parents and health care providers, and there is often a lot of tension surrounding the practice.  Below, you will find a summary of the most current and comprehensive peer-reviewed evidence available on the safety of out-of-hospital birth.  Evidence on other birth-related topics such as Vitamin K injection and erythromycin eye ointment at birth, or Group B Strep in pregnancy can be found at Evidence Based Birth.

There is ongoing research on the benefits of home birth, and studies have demonstrated a number of positive effects for mothers and babies, including improved maternal experience and decreased use of medical interventions.  These results are an encouragement to women considering home birth and the providers who perform it, but the primary question TexasHomeBirth will address is:

How Safe is Planned Home Birth in Texas?

Evidence on safety of home birth in Texas, specifically, is limited.  That is, there really isn’t any.  So we must look to national data to compare.

According to the National Vital Statistics Report on Birth for 2015, the rate of home birth in the United States has been growing. In 2015 (the most recent national figures available), out-of-hospital deliveries represented 1.5% of births in 2015. This is the highest number since national reporting on home births began in 1989.  Of the more than 61,000 out-of-hospital births in the United States in 2015, 63.1% occurred in a residence (home) and 30.9% in a freestanding birthing center.  This growing trend makes it especially important that Texas women have access to reliable information about the safety of home birth.

Home birth is a tough subject for researchers to investigate using a high-quality study.  This is mostly because taking any unnecessary risks with the lives of mothers and babies is unethical.  Researchers can’t ethically sort mothers to deliver in different situations that might be dangerous just to record what happens.  Expecting moms are also (understandably) not wild about the idea of being randomized into a group for either home or hospital birth.  So most of the data we have to rely on is from what’s called “observational” study design.  Observational studies are often surveys, case-control studies or cohort studies.  A survey study sounds like what it is, a survey of information reported by a person or group.  In a case-control study,  researchers ask a question that requires them to look backward in time, comparing those with and without the outcome of interest.  This means researchers collect information about OOH birth from women who chose it, or from providers who perform it, or from state/patient/hospital records.  Unfortunately, this information often has reliability issues because we’re relying on people to be honest or remember correctly, or relying on records to be accurate in hopes of finding out the truth.

There have also been cohort studies performed on home birth.  These studies give us the advantage of following a group of moms forward in time to see what happened to them or their baby when they delivered outside the hospital. However, we don’t have as much ability to compare them to other moms who chose a different type of birth or to moms who were different from the women studied.

To learn more about Levels of Evidence and why some types of research are more trustworthy or reliable than others, please watch this video or read this.

Another limitation is that a lot of the available research was conducted abroad, where home birth is tightly controlled or totally integrated into the medical system of that country, such as the Netherlands or in Canada.  Results from these studies might not apply in the US, where the circumstances are much different.  Many studies conducted are also too small and therefore don’t carry enough statistical weight to guide our healthcare decisions.

So, the evidence available on planned home birth safety is not of ideal quality, but we’ll work with what we’ve got.

The largest study on home birth in America to date is a compilation of survey data gathered by the Midwives Alliance of North America on 16,924 planned home births from 2004 to 2009.  It was published in the Journal of Midwifery and Women’s Health here.  This statistics project is ongoing and data is voluntarily self-reported by midwives across the nation about their clients, births, and outcomes.  We’ll cover this paper specifically because it is frequently promoted by midwives and home birth advocates nationwide.  Please review the above links to understand the limitations of survey data.

The paper’s abstract states:

“For this large cohort of women who planned midwife-led home births in the United States, outcomes are congruent with the besavailable data from population-based, observational studies that evaluated outcomes by intended place of birth and perinatal risk factors. Low-risk women in this cohort experienced high rates of physiologic birth and low rates of intervention without an increase in adverse outcomes.”
At first glance, this sounds encouraging.  But closer examination reveals some interesting information.
“The overall death rate from labor through six weeks was 2.06 per 1000 [this is the neonatal period] when higher risk women (i.e., those with breech babies or twins, those attempting VBAC, or those with preeclampsia or gestational diabetes) are included in the sample, and 1.61 per 1000 when only low risk women are included. This rate is consistent with some published reports of both hospital and home birth outcomes, but is slightly higher than others.”
According to the CDC Wonder database, the neonatal death rate for a comparable group of infants born in the hospital, with congenital abnormalities excluded, is at most 0.7 per thousand.  The combined neonatal (after birth) and intrapartum (during labor) death rate for the MANA STATS group, with congenital abnormalities excluded, was 2.06 per thousand, which is 2.9  times higher.

The outcomes broken up by a few specific risk factors are:

  • Breech presentation: The MANA STATS mortality rate for breech presentation was 22.5 per 1000 live births.  The national mortality rate for breech presentation in the hospital is no worse than for babies with cephalic (normal, head-down) presentation – 1.8 per 1000.
  • The Trial Of Labor After Cesarian (TOLAC) infant death rate was 5 out of 1052 (4.75 per thousand).  This is significantly higher than the hospital comparison rate of 0.7 per thousand.
  • 15.5% of the mothers in the MANA STATS group experienced a postpartum hemorrhage over 500ml, with 4.8% losing over 1000mL.  Nationally, only 3.3% of hospital vaginal births resulted in a postpartum hemorrhage exceeding 500 ml.  This is a significantly increased risk of postpartum hemorrhage.

The above analysis of the MANA STATS data was conducted by statistics professor, Brooke Orosz, PhD.  You can read the entire analysis here.   There is a lot of statistical vocabulary and the analysis is complex.  If you have questions about the analysis, please feel free to email

Based on the MANA STATS data, and on the entire collection of home birth evidence available to date, the American College of Obstetricians and Gynecologists has issued a Committee Opinion on Planned Home Birth.  The opinion statement unpacks much of the research that is not mentioned here, and would be valuable information for any woman considering home birth in the United States.

The College acknowledges the documented benefits of planned home birth and of the Midwives Model of Care.  The College also asserts that it is any woman’s right to birth wherever and with whomever she chooses.  Overall, ACOG has softened its stance on OOH birth in the past decade, providing recommendations for safety rather than condemning the practice altogether.  The College remains concerned, however, about the safety of OOH birth in this country, specifically.  There is a significant amount of change that must occur in the way our country handles home birth if we want to see the kind of positive outcomes that exist in Europe and Canada.